Have you ever been convicted of or admitted to committing a felony or any of the following criminal offences in this stat e or similar offences in another state or jurisdiction?*

Yes

No

Contributing to the delinquency

Aggravated assault of a minor

Sexual abuse of a minor

Incest

First or Second Degree murder

Kidnapping

Arson

Sexual Assault

Burglary

Robbery

Child abuse

Sexual conduct with a minor

Molestation of a child

A dangerous crime against children, aggravated assault committed against a minor less than 15 years of age resulting in a serious physical injury or committed by the use of a deadly weapon or dangerous instrument.

Felony offences involving distribution of marijuana or dangerous or narcotic drugs
Includes crimes listed herein involving a minor under 15 years of age.

Signature

Date*

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for volunteering and that the answers given by me are true and correct to the best of my knowledge. I understand that any omission of misstatement of material fact on this application will be grounds for rejection of this application or for immediate dismissal, regardless of the time elapsed before discovery.

*

I agree to the content stated above

To the fullest extent permitted by law, I hereby fully waive,release, protect, and hold harmless the Boys & Girls Club of Truckee Meadows, together with all its agents, employees, representatives, officers, and
directors from any and all claims, causes of action, damages, costs, expenses, and other liabilities in any way arising out of or resulting from my volunteer opportunity and participation, including, but not limited to, any personal injury, accident, illness, property damage, or any other loss, injury, or harm whatsoever.

*

I agree to the content stated above

In order to safeguard the well-being of the youth served by our organization, I authorize the Boys & Girls Club of Truckee Meadows to verify all information provided by me on this application. I hereby authorize any reference listed on this application and/or any educational entity or person on this application to disclose to the organizations any and all letters, reports and other information related to my work or educational record, without giving me prior notice of such disclosure. In addition, I hereby release the organization, my former employers, all educational entities listed on this application and all other persons or organizations from any and all claims, demands, or liabilities arising out of in any way related to such investigation or disclosure.